By Claire Thayer, April 27, 2017
According to the National Health Care Anti-Fraud Association, most health care fraud is committed by organized crime groups and a very small minority of dishonest health care provider. The NHCAA tells us that the most common types of fraud include:
· Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.
· Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code).
· Performing medically unnecessary services solely for the purpose of generating insurance payments.
· Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs.
· Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.
· Unbundling - billing each step of a procedure as if it were a separate procedure.
· Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
· Accepting kickbacks for patient referrals.
· Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to "financial hardship").
While the U.S. Department of Justice, FBI, CMS and other government entities are busy identifying and tracking down fraud schemes, Deloitte research points out that an emerging area of interest in health care fraud and abuse enforcement is that of relationship scrutiny.
This weeks’ edition of the MCOL Infographic, co-sponsored by LexisNexis, highlights some of the costs associated with fighting healthcare fraud:
Entries in Cost & Utilization (78)
Reducing Emergency Visits and Admissions for Epilepsy Patients: Nationwide Children’s Dr. Anup Patel Answers Our Questions
By Clive Riddle, April 14, 2017
What can a single quality improvement project accomplish at a single hospital? Just ask Nationwide Children’s, who performed a quality improvement project and found new, simple ways to significantly decrease the number of emergency department visits and hospitalizations in pediatric patients with epilepsy.” They achieved a 28% decline in emergency visits, a 43% decline in admissions and saved $2 million in costs for these patients.
By sharing their research findings in the current issue of Pediatrics, and highlighted in Nationwide Children’s research publication Research Now, hospitals, physicians and purchasers performing care management can adopt Nationwide’s approach to their own settings.
We are told that “Nationwide Children’s Hospital serves almost 3,500 children diagnosed with epilepsy. In 2012 and much of 2013, the Emergency Department was experiencing approximately 17 visits per 1,000 epilepsy patients per month. In the minds of both Emergency Medicine physicians and epilepsy subspecialists, that was too many.”
The hospital shares that “the QI team identified ‘key drivers’ (or contributing factors) of ED visits, and found they centered on provider-to-provider communication issues and patient/family resources, education, beliefs and comorbidities. Then the team began interventions to target those key drivers. Most important was the establishment of an Urgent Epilepsy Clinic,” which they tell us involved family visits lasting 90 minutes or longer, with as little as three days’ notice.
Nationwide Children’s also identified that “abortive seizure medication was under dosed (or not given at all). Nationwide Children’s built an alert system into its electronic health records – when a provider entered what appeared to be an incorrect dosage based on size and age, the provider would be notified of the proper dose.” Their additional interventions developed from the project included a color-coded seizure action plan, which helped caregivers understand what a baseline seizure looks like and when to call Neurology; and a personalized magnet giving caregivers information about how to give abortive seizure medications.”
The results? Emergency visits reduced from 17.0 to 12.2 per month per 1,000 children epilepsy patients during the past year. The average number of inpatient epilepsy children hospitalizations per month was reduced from 7 admissions per month per 1000 patients to 4 admissions per month per 1000 patients.
Anup Patel, MD, a pediatric epileptologist and member of the Division of Neurology at Nationwide Children’s, and leader of the QI project and resulting research paper was nice enough to respond to some follow-up questions I asked after reading about the project.
First, I asked him what is the approximate epilepsy incidence/1,000 population (pediatric preferably). He shared this information from Epilepsy.com which he recommends as a great source information on epilepsy:
Epilepsy is the 4th most common neurological problem – only migraine, stroke, and Alzheimer’s disease occurs more frequently. There are many different ways to explain how often a disease occurs. Here’s a few points to consider.
What is the incidence of epilepsy in the United States?
· The average incidence of epilepsy each year in the U. S is estimated at 150,000 or 48 for every 100,000 people.
· Another way of saying this- each year, 150,000 or 48 out of 100,000 people will develop epilepsy.
· The incidence of epilepsy is higher in young children and older adults. This means that epilepsy starts more often in these age groups.
· When the incidence of epilepsy is looked at over a lifetime, 1 in 26 people will develop epilepsy at sometime in their life.
· Seizures are the number on most common Neurologic Emergency that we see in children.
What is the prevalence of epilepsy in the United States?
There are many different estimates of the prevalence of epilepsy. These numbers vary depending on when the studies were done, who was included, and a host of other factors.
· The number of people with epilepsy, using prevalence numbers, ranges from 1.3 million to 2.8 million (or 5 to 8.4 for every 1,000 people).
· The estimate currently thought to be most accurate is 2.2 million people or 7.1 for every 1,000 people.
· However, higher numbers of people report that they have active epilepsy, 8.4 out of 1,000 people. These numbers are even higher when people are asked if they have ever had epilepsy (called lifetime prevalence). 16.5 per 1,000 people reported that they had epilepsy at some point in their life.
Next I asked him about the second intervention in the project regarding abortive seizure medication under dosed or not given. How much is medication adherence/compliance an issue for this population? Dr. Patel responds that “We know that medication adherence to daily seizure medications is a risk factor for ED visits in patients with epilepsy. In regards to abortive seizure medication (medication given for long or repeat seizures), we found under dosing was an issue (previous literature – Patel in Epilepsy and Behavior 2014) and that parents were either anxious, did not remember, or did not get proper instruction on how to give medications.”
Noting that the project identified comorbidities as a key driver, I asked him what are the typical comorbidities? He replied “Developmental delay, autism, cerebral palsy, depression, and anxiety.”
I asked Dr, Patel to elaborate on the calculation that their interventions yielded $2 million in annual savings. He responded that “our average ED visit was $640 and a subsequent hospitalization averaged $14,500 in claims paid. When you look at the reduction of both ED visits and the hospitalizations associated with the ED visit, you get the $2 million savings per year”.
Lastly, I asked if a similar approach work for an adult population as well. The short answer is yes.
By Clive Riddle, April 7, 2017
The Associated Press reports that Dr. Scott Gottlieb, “the doctor nominated to head the powerful Food and Drug Administration told senators Wednesday that his first priority would be tackling the opioid crisis.”
What are health plans doing about Opiod Abuse? Last June, the California Health Care Foundation released a report taking the issue on: Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic, along with companion California health plan case studies and an infographic. Nationally, last fall AHIP weighed in, discussing how health plans are Fighting Opioid Abuse With Solutions That Work.
So what are some current developments on the health plan Opioid Abuse front?
Cigna has just announced that Use of Prescribed Opioids Down Nearly 12 Percent Over 12 Months Among Cigna Customers. Cigna reports that “58 medical groups participating in Cigna Collaborative Care, representing nearly 62,000 doctors, have signed Cigna's pledge to reduce opioid prescribing and to treat opioid use disorder as a chronic condition.”
Cigna states that their program works with participating doctors to: (1) Analyze integrated claims data across pharmacy and medical benefits to detect opioid use patterns that suggest possible misuse by individuals, and then notifying their health care providers; (2) Alert doctors when their opioid prescribing patterns are not consistent with CDC guidelines; and (3) Establish a database of opioid quality improvement initiatives for doctors.
Cigna also reports that “effective July 1, most new prescriptions for a long-acting opioid that are not being used as part of treatment for cancer or sickle cell disease, or for hospice care, will be subject to prior authorization, and most new prescriptions for a short-acting opioid will be subject to quantity limits.”
Last week the Wisconsin Association of Health Plans announced their member plans have jointly committed to combating opioid abuse and addiction in Wisconsin and effective April 1, Wisconsin's community-based health plans are collaborating on new initiatives. The Association members agreed to: (1) support the Association’s Statement of Principles for addressing opioid abuse that “form the basis for sharing information, best practices and evidence-based strategies”; (2) Track morphine equivalent dose and first-time user trends for their individual and employer group members,, generating comparative data to enrich provider education and management of prescription drug formularies and coverage policies; (3) Work with provider partners to support strategies to reduce and control the level of opioid prescribing; (4) Share methodologies, best practices and evidence-based strategies to improve the quality of pain management and opioid prescribing; and (5) Ensure that every member suffering from opioid abuse has access to medically-appropriate treatment options.
Two weeks ago BlueCross BlueShield of Western New York released episode four of their Point of Health Audiocast, “Addressing the Opioid Epidemic from a Health Plan Perspective,” aimed at increasing awareness of the issue and engaging stakeholders.
FamilyCare Health, a health plan serving Oregon Medicaid and Medicare members, “kicks off its 4-part Opioid Training series for providers on Thursday, April 27, 2017 with ‘Buprenorphine: What we know and what we don’t. Prescribing safely for pain management and opioid dependence.’ “
And last week, Prime Therapeutics, the Blue Cross Blue Shield Association PBM, released two studies, highlighting strategies for addressing opioid epidemic. The first study “analyzed concurrent use of opioids with benzodiazepines”, citing “previous research has shown concurrent use of these two types of drugs can increase the risk of overdose and death,” and “found more than one in six opioid users without cancer – or nine per 1,000 commercially insured members – used these two drugs concurrently for 30 days or more in 2015.” Their second study “found pharmacists based in a PBM or health plan, who do outreach to prescribers, can reduce emergency room visits and controlled substance drug costs among persistent users of controlled substances.” Following the outreach conducted with the study intervention group, “controlled substances drug costs per member for the intervention group dropped from $5,802 to $5,148, while controlled substance drug costs increased for the control group from $3,511 to $3,627 per member. Emergency department visits were 6.4 percent lower in the intervention group, compared with the control group.”
by Kim Bellard, December 14, 2016
Health care fraud is bad. Everyone agrees about that (except those who profit by it). We'd similarly agree it is all too pervasive. Some estimate that fraud could account for up to 10% of health care spending. But that's chump change: estimates are that other kinds of wasteful spending, such as unnecessary care and excessive administrative costs, are easily double that.
An op-ed in The Boston Globe may have it right: we need an overdiagnosis awareness month.The op-ed was a tongue-in-cheek suggestion to highlight the various cancer awareness months, the most famous of which is October's Breast Cancer Awareness. These campaigns promote the need for the associated screenings, but don't typically also mention how controversial many of them are.
Overdiagnosis goes much further than screenings. As Atul Gawande wrote last year, we're getting an "avalanche of unnecessary care," getting too many services of not just low value but of at best no value to patients -- and, at worse, actually harmful to them. Not just pointless tests or unneeded prescriptions, but also too many questionable procedures, such as total knee replacements, heart stents, or spinal fusions.
The real problem is that most people involved in the "epidemic" of overdiagnosis and over-treatment our health care system, well, they think they're just doing their jobs.
They don't think they're trying to rip anyone off, they certainly don't think that they're harming anyone, and they most definitely don't think their role is superfluous. This is all only possible because it is still too hazy about what is the right treatment for who, when, not to mention what a "fair" price might be for anything. So, when in doubt, do more.
As a result, health care employment is booming. Some project it will be largest job sector within three years. Indeed, as the chart below shows, virtually all of the U.S. job growth this century has been in health care jobs. That, quite simply, is astounding.
Yet, despite all this growth, there continue to be urgent cries of shortages of key health care professionals. We just cannot seem to get enough qualified health care workers. If you're looking for a job, that's good news, but if you're paying the bill for all those jobs, it should be scary.
In health care, we just add more jobs.
Overtreatment works, at least if you're the one doing the treating.
And everyone in health care keeps doing their job.
Look, this fantasy isn't going to continue. Health care isn't going to become 100% of GDP. It's not going to get to 50%, or 40%. At some point the revolt will happen, the revolution will occur, and health care spending will finally slow, stop, and eventually plunge.
Then all those health care jobs are not safe. People will lose their jobs. A lot of people. People who, until then, thought they were doing good.
So when the next health care innovator comes along, we should try to get past the hype and ask: OK, specifically, what jobs will this eliminate -- which ones, how many, when? If they don't have answers, or only offer vague promises, well, smile politely and get out your wallet.
In health care, perhaps one way to do your job might just be to find a way to eliminate it.
By Clive Riddle, September 30, 2016
The just released current Kaiser Family Foundation Tracking Poll finds that while the public continues to be deeply divided on the Affordable Care Act, they are fairly united in backing policy changes to rein in prescription drug costs. The level of bipartisan public support – powered by recent EpiPen pricing headlines among other Rx cost woes in the news - would seem to offer a prescription paving the way for a rare event these days– legislation that has a chance of being enacted into law when the new Congress convenes next session.
There is widespread agreement on five policy points:
- 86% support requiring drug companies to release information to the public on how they set drug prices
- 82% favor allowing the federal government to negotiate with drug companies to get a lower price on medications for people on Medicare
- 78% approve of limiting the amount drug companies can charge for high-cost drugs for illnesses like hepatitis or cancer
- 71% like allowing Americans to buy prescription drugs imported from Canada
- 66% want an independent group that oversees the pricing of prescription drugs
Here’s a graphic Kaiser Family Foundation provided regarding the poll results:
The survey finds that “a large majority (77%) perceive drug costs as unreasonable, while one in five (21%) say they are reasonable. The share who say drug costs are unreasonable is up somewhat from 72 percent a year ago in August 2015.” The Survey also finds that “about half (55%) of the public report currently taking prescription drugs, and the vast majority (73%) of them say paying for their medications is easy; far fewer (26% of those taking prescription drugs, or 14% of the total population) say it is difficult to pay for their drugs.”
The September tracking poll continues to reflect the deep partisan divide in views on the ACA, which spill over to recognition of a significant drop in the level of the uninsured:
- 47 percent have an unfavorable view of the ACA while 44 percent have a favorable one.
- 48% say the marketplace in their own state is working well, while 43 percent say it is not working well, but 49% say they are not working well nationally vs. 44% that say they are working well.
- “When asked whether the uninsured rate is at an all-time low or all-time high, a quarter (26%) are aware that it is at an all-time low, while a fifth (21%) say that it is at an all-time high. Democrats and those with a favorable view of the health reform law are more likely to be aware of this; Republicans and those with an unfavorable view are less likely to be aware.”
With regard to the current level of the uninsured, HHS this week released a report indicating “the uninsured rate fell by around 40 percent for Americans in all income groups for 2010 through 2015, including individuals with incomes above 400 percent of the federal poverty level (FPL).”
Here’s the levels of reduction in the rate of uninsured they found during this time period by income levels and age:
- Less than 100% FPL: 39% reduction
- 100-125% FPL: 48% reduction
- 125-250% FPL: 41% reduction
- 250-400% FPL: 37% reduction
- 400% FPL and higher: 42% reduction
- 18-25 year olds: 52% reduction
- 26-34 year olds: 36% reduction
- 35-54 year olds: 39% reduction
- 55-64 year olds: 40% reduction